Federal Air Surgeon’s Medical Bulletin

Federal Air Surgeon's

Medical Bulletin

02-4 Winter 2002

Aviation Safety Through Aerospace Medicine

For FAA Aviation Medical Examiners, Office of Aerospace Medicine Personnel, Flight Standards Inspectors, and Other Aviation Professionals.

U.S. Department of Transportation Federal Aviation Administration

HEADS UP Q

2 Editorial: Research and Aviation Safety

3 Certification Issues and Answers

6 Bariatric Surgery: How Long to Wait?

7 Checklist for Pilot Physical

8 Palinopsia Case Report

9 Factors in Human Error

11 Hydrocephalus Case Report

12 AAM News 13 AME Seminars 14 Health of

Pilots: Your Heart & Exercise 16 Index of 2002 Stories

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Best Practices

This article launches Best Practices, a new series of

A Dean Among Doctors

profiles highlighting the shared wisdom of the most senior of our senior aviation medical examiners.

By Mark Grady

Written by one of Dr. Moore's pilot medical

General Aviation News

certification applicants, this article appeared in

DOCTOR W. DONALD MOORE of Coats, N.C., knows a lot of pilots -- many quite intimately. After

the November 22, 2002, issue of General Aviation News. --Ed.

all, as an Federal Administra-

morning just to give medical

tion Aviation Administration-

exams for pilots in the area.

approved medical examiner,

He estimates he's given more

he's poked and prodded quite

than 12,000 flight physicals

a few of them during his more

over the past 41 years.

than 40 years of making sure

"I've given an average of

they meet the FAA's physical

300 flight physicals a year since

requirements for flying.

1960," he says, noting those

He also knows what it's like

exams have been in addition

to fly, because he flew for 40

to running a busy general

years.

medical and obstetrics

Moore began giving FAA physicals in 1960, the same

Dr. Moore, shown in his Coats, N.C., office

practice. While he majored in Greek

year he learned to fly. Now

and English at Wake Forest,

83 years old, he is not as active at his Moore was always interested in the sci-

medical clinic as he once was, but he still ences. He couldn't escape an interest in

ventures in for an hour or two each

Continued on page 5

Quick Fix

By Richard F. Jones, MD, MPH

PROBLEM

Student pilots are sometimes receiving an FAA Form 8500-9, Medical Certifi-

cate, instead of an FAA Form 8420-2, Medical Certificate and Student Pilot

Certificate, at the time of their FAA medical examination.

Another part of this problem is where an applicant has requested a combined

Medical and Student Pilot Certificate in block 1 on the 8500-8 form, but the

aviation medical examiner (AME) indicates in block 62 of the form that only a

Medical Certificate has been issued.

RESULT

If only a Medical Certificate is issued, student pilots are flying without valid

certificates and are subject to disciplinary action when caught. These student

pilots are often very hostile toward the AME who failed to issue the appropriate

certificate.

Continued on page 10...

Aerospace Medical Research: Making Air Travel Safer

The Federal Air Surgeon's Column

TO MANY PERSONS outside the Federal Aviation Administration (FAA), the Office of Aerospace Medicine's greatest visibility relates to our administration of the airman medical certification system. There is good reason for this since ensuring that airmen meet sound medical criteria and are free of drugs and alcohol have long been considered our highest priorities. Sometimes overlooked are the significant contributions and support our research organizations provide, not only to the certification process but also to the overall safety of the national airspace system.

The FAA is blessed with having two "World Class" research organizations at the Civil Aerospace Medical Institute (CAMI). Much of the work carried out by these two research organizations

Federal Air Surgeon's Medical Bulletin

Secretary of Transportation Norman Y. Mineta

FAA Administrator Marion C. Blakey

Federal Air Surgeon Jon L. Jordan, MD, JD

Editor Michael E. Wayda

The Federal Air Surgeon's Medical Bulletin is published quarterly for aviation medical examiners and others interested in aviation safety and aviation medicine. The Bulletin is prepared by the FAA's Civil Aerospace Medical Institute, with policy guidance and support from the Office of Aerospace Medicine. An Internet on-line version of the Bulletin is available at: AAM-400A/fasmb.html

Authors may submit articles and photos for publication in the Bulletin directly to:

Editor, FASMB FAA Civil Aerospace Medical Institute AAM-400 P.O. Box 25082 Oklahoma City, OK 73125 e-mail: Mike.Wayda@

is accomplished quietly and without a

great deal of fanfare. I can assure you,

however, that the contributions these

organizations make to system safety

provides a big "bang" for the relatively

small expenditure of dollars that go to

their support.

Human Resources. Research psy-

chologists and supporting staff comprise the Human Resources Research

By Jon L. Jordan, MD, JD

Division. Their goal is to improve aero-

space safety and workforce performance hard work by the staff at CAMI, what

through human factors research. In began as a cast-off hunk of metal has

plain language, these folks play a major become a unique, multi-purpose, highly

role in identifying environmental and sophisticated, research facility.

other factors that impact pilot and air

Thus far, the facility has been used

traffic controller performance and cause for a number of research tasks. In-

or contribute to accidents. Among oth- cluded among these is the training of

ers things, the research includes human aircraft accident investigators as well as

performance under various conditions security personnel for dealing with hi-

of impairment, human error analysis jackers and unruly passengers. The fa-

and impact of advanced automation cility is equipped to investigate cabin

systems on personnel performance.

airflow that will define molecular, par-

Medical Research. The other divi- ticulate, and microorganism dispersion

sion, the Aerospace Medical Research and aid in studies of contamination of

Division, is composed of a more het- cabin and cockpit air from a variety of

erogeneous group of scientists. Among potential sources, including possible

others, included are re-

acts of terrorism. Most

search physicians, chem-

recently, the facility was

ists, and engineers. To

used to determine the

name just a few, these

time required to secure a

folks engage in accident

passenger cabin follow-

investigation from the

ing a warning of air tur-

medical perspective,

bulence. This research

look for ways to improve

was in support of NASA

occupant protection and

for the development of

survival in the event of

an early-warning system

an accident or other life-

for air turbulence. Fu-

threatening event, and

Wide-Body Research

ture potential uses for

identify physiological,

Facility at CAMI

the facility are virtually

psychological, and per-

limitless.

formance factors that threaten safety.

Those of you who have had the

It is impossible to cover in this col- opportunity to visit CAMI recently are

umn all the important aviation safety familiar with the current high level of

contributions being made by our two sophisticated research going on there.

research organizations. I feel compelled, For others who have never been there or

however, to mention at least one. This have only a dim recollection of our

is the wide-body environmental research research activities, I simply wanted to

facility that was completed in 2001. let you know or remind you of the

The wide-body research facility was dedicated and highly professional staff

developed through refurbishing the hull that-- in many ways-- is working to

of a scrap Boeing 747 aircraft. Through make air travel as safe as it can be.

ingenuity in securing funds and a lot of

JLJ

2 T h e F e d e r a l A i r S u r g e o n ' s M e d i c a l B u l l e t i n ? Winter 2002

Certification Issues and

1 A 22-y/o airman has a single episode of spontaneous pneumothorax and applies for a 1st-class medical certifi-

9 An airman who last had an FAA medical certificate in 1992 has a history of chronic tension headaches. He writes

Answers

cate. What do you need to provide the in Block 17 that he takes Ultram? AMCD? Can you grant medical certi- (tramadol hydrochloride) and Flexeril?

fication?

2 By Warren S. Silberman, DO, MPH

A 45 y/o airman develops a bout of paroxysmal supraventricular tachycardia. Can you issue a 3rd class medical

(cyclobenzaprine HCL) for the headaches. He has been averaging four headaches per month, and they seem to occur when his boss "gets on his case"

certificate for this?

about things. The headaches are linked

O 3 ne of our hard-working medical review physicians, Larry F. Wilson, MD, is in the Okla-

Does the AMCD grant medical certification after an airman suffers a pulmonary embolus? What if the air-

with nausea and photophobia. Noises seem to make them worse. He must get to a dark room and try to rest when he

homa Army National Guard and has man is still on Coumadin??

gets one of them. He claimed that he

4 been mobilized for at least one-year [see

story, page 12]. This has resulted in quite a strain on our other physicians,

An airman comes to your office for an initial flying examination. On examination, you note that he has a

only takes the Flexeril? when he has to, but the Ultram? works quite well. You issue an unlimited medical certificate.

and we pray for his safe return.

scar from childhood that goes across Were you right?

I am requesting that you aviation medical examiners who regularly call the Aerospace Medical Certification

10 his orbit, and the cicatrix essentially

resulted in a profound ptosis of the eyelid. You wonder if he has adequate

What are the five mental healthrelated specifically disqualifying illnesses?

Division to speak with one of our physicians to be patient and to utilize

11 our Physician of the Week (POW) for

all questions relating to medical certification. When phoning into

5 12 AMCD to speak to the physician and

field of vision in that eye. Should you issue the medical certificate?

A pregnant airman, just initiating her third trimester, applies for a 2ndclass medical certificate. What should you do?

What criteria do the FAA consider in making the diagnosis of substance dependence?

An individual who had an Authorization for Special Issuance for substance dependence came in for an

6 that line is busy, the operator will ask

you for a good phone number where we can reach you. Should you have an

Airman Bubba Ray Beauregard applies for a 1st-class medical certificate. Three months ago, he passed a

examination and informed you that she only had about four glasses of wine after work each day. Would you give

airman in the office and want our calcium oxalate stone. He provides a her a medical certificate?

verbal authorization for a special issuance, you may want to tell the airman you will be in touch after

13 note from his treating urologist stating

that Bubba has retained a 4mm stone in the upper pole of the right kidney

Airman Potawanamie Pauly, 35, presents for a 1st-class medical certificate and gives the following history. He

speaking with us. We want to keep and that if he drinks plenty of fluids, he answered "yes" to question 18 w., which

the phone calls to physicians who are may not pass the stone. What should asks applicants to list their history of

not manning the phone left alone so you do?

nontraffic convictions (misdemeanors

7 they can perform their case reviews.

The POW will return your call. You need to also be aware that

An airman in chronic renal failure on hemodialysis three times per week requests a 3rd-class medical cer-

you may phone your Regional tificate. He demonstrates stable elec-

or felonies). When he was 16, Pauly received five tickets for speeding, and the police came to his home and arrested him for nonpayment of the fines.

Medical Office for medical certifi- trolytes, BUN, and creatinine. He At age 18, he was arrested for stealing

cation questions.

appears to be alert and oriented. He has acne cream from a local drugstore. At

Now, I am going to continue with some hypertension, which is adequately 20, and while a student in political

our questions and answers, all of treated. Since he "looks great," the science at Yale, he was arrested for the

which are referenced to the 1999 AME issues an unrestricted medical rape of a freshman law student, but the

Guide for Aviation Medical Examin- certificate. Was she right?

charges were ultimately dropped. He

8 ers. The appropriate page numbers

are in parenthesis after each answer.

An applicant for student pilot 1stclass medical certificate has had an amputation above the right elbow. He

was arrested for cocaine possession at age 27 and spent two years in a Federal prison. It seems that his friend asked

wears a prosthesis, but the extremity is him to drive his car to pick up some

pretty much nonfunctional. The re- other guys at a not so good part of town.

mainder of his flight exam is benign. He really didn't know that in the trunk

Dr. Silberman manages the Civil Aero- What should you do? space Medical Institute's Aerospace Medi-

of the car was a kilo of cocaine, so when the police stopped the car for having an

cal Certification Division.

Continued, answers on page 4...

T h e F e d e r a l A i r S u r g e o n ' s M e d i c a l B u l l e t i n ? Winter 2002 3

Issues & Answers from page 3

out-of-date license plate, well, you know what happened from there! Pauly now tells you that all these events were due to a lack of maturity, and he has seen the error of his ways, and wants to become an airline transport pilot. Should you issue the medical certificate? Does this story sound right to you?

ANSWERS TO THE QUIZ QUESTIONS

1: To make a decision, we need to have the hospital and/or emergency room admission and discharge notes that describe the event. We need to know the treatment provided and some proof that it was successful. If you could provide some statement from the treating physician of the likelihood of recurrence, this would also be helpful. If the airman has a completely expanded lung and there has been no recurrence, you may grant medical certification. You MUST provide AMCD with all the information (AME Guide, page 45).

2: No, you cannot! An AME should provide the medical records that describe the event and surrounding circumstances. We will need a current status report that mentions the workup that was accomplished. The workup should have included thyroid function studies, 2 D echocardiogram, and 24 hour Holter Monitor. If there are increased cardiac risk factors, then a maximal Bruce Protocol Stress test should be performed (page 46).

3: An airman who suffers a pulmonary embolus can gain medical certification. We usually would like to know that all potential etiologies have been evaluated to include hypercoagulable states. An airman who is taking an anticoagulant can also be

medically certified. The airman should be stabilized on the Coumadin? for at least one month and all the International Normalized Ratio values should be provided, all of which should be within the therapeutic range. This will result in an Authorization for Special Issuance (page 49).

4: No. You should obtain an eye evaluation with field of vision and forward the case report to the AMCD (page 53).

5: Perform the exam and, if she is otherwise normal, you may issue an unlimited medical certificate. I would caution the airman about the risk of injury secondary to the aircraft restraint systems, but pregnancy is not, in itself, disqualifying (pages 55-6).

6: Defer to the AMCD. We would like to see some type of imaging procedure to note the exact site and size of the stone. Unless this stone was embedded in the kidney cortex, he will likely get a denial (page 55).

7: No, she wasn't! We do not grant medical certification to any airman for any class when they are on hemodialysis. We have granted medical certification to airmen who are stable receiving peritoneal dialysis. Recall that patients who are in chronic renal failure on dialysis are in a precarious metabolic situation requiring strict diet control and fluid balance. We will grant medical certification after they receive a renal transplant and demonstrate 6 months of stability. We do accept most of the antirejection medications (page 55).

8: The applicant will require a Statement of Demonstrated Ability (SODA). You should defer the case to the AMCD, but also have the applicant provide a letter requesting the SODA. This request will also result in the FAA administering a medical flight test in the aircraft that the applicant is familiar with. If the

applicant needs some modification of the aircraft, this will be noted. The applicant will also receive a notation on his airman certificate that his flying is limited to the particular aircraft in which the test was taken (page 57).

9: No, you were not! Both Ultram? and Flexeril? are unacceptable for flying duties. Both of these medications cause sedation. The other significant issue is the headaches, themselves. The airman appears to be having too many of them to allow medical certification at this time. Perhaps the AMCD would allow certification if the airman would try some nonsedating medications or biofeedback, and the headaches were less frequent and debilitating (page 63).

10: 1) psychosis, 2) bipolar disorder, 3) personality disorder manifested by overt acts, 4) substance dependence, 5) substance abuse (page 3).

11: 1) increased tolerance; 2) manifestation of withdrawal symptoms; 3) impaired control of use; or 4) continued use despite damage to physical health or impairment of social, personal, or occupational functioning (page 67).

12: No, I surely hope not! Note in Part 67 that the FAA does not grant medical certification to an airman with a known diagnosis of substance dependence until the airman can demonstrate total abstinence. This total abstinence also becomes a requirement of any future medical certification and is written into their authorization letters (page 66).

13: Fellow AMEs, what part of this story sounds right to you? Do you recall the specifically disqualifying condition, personality disorder manifested by overt acts? Do you think this diagnosis fits this case? It certainly does. Issuing a medical certificate is not appropriate in cases such as this.

Q

4 T h e F e d e r a l A i r S u r g e o n ' s M e d i c a l B u l l e t i n ? Winter 2002

Doctors' Dean from page 1

BEST PRACTICES

DR. MOORE'S SUGGESTIONS FOR A SUCCESSFUL AVIATION MEDICINE PRACTICE

medicine and what he believes was a calling to become a medical missionary. He accomplished that goal by serving in a 100-bed, Baptist-run hospital in southern China for two years in the late 1940s. The missionary hospital treated patients who would not have access to or been able to afford decent medical care. The Communist-run Chinese government eventually ran Moore and other missionaries out of the country. He returned to the states on a different type of mission.

"When the doors closed in China, I felt I needed to be in a small community where the need was the greatest," he said.

Coats, a small town in the heart of North Carolina, became his new mission field. He set up practice there in 1949. Today, pilots and other patients still make their way to Coats Medical Clinic, which features two other doc-

1. Pilot area. Have a separate place for pilots (especially if the practice has patients other than pilot applicants) for FAA materials to be displayed and organized. It could be located in the waiting area; it is a place for pilots to read, work on forms, and not be interrupted.

2. Office assistant. Have a very knowledgeable assistant. Our nurse, who schedules work for us, has doing it long enough to be able to answer all technical questions about forms, procedures, and so on. She was trained at the FAA seminar, which was very helpful.

3. Regional Flight Surgeon. Contact with the regional office is always very helpful. We enjoy our contacts with the regional office because they are knowledgeable and easy to talk with. You can discuss any questions that affect the certification outcome with them.

4. Pilot status. I recommend that all AMEs be pilots because they can better understand various situations as they arise. While I lost my own medical and am no longer eligible to fly solo, I still enjoy flying with others.

5. Be engaged in the aviation community. Speak at safety seminars, get involved in some of the seminar discussions, get to know the pilots in your area. Perspectives vary and you can promote aviation safety while in the health care business. I feel a great sense of responsibility for my pilots' safety.

tors, including his daughter, Dr. Linda Robinson. She added the AME designation to her list of medical credentials a few years ago. She performs the flight physicals her father's reduced schedule can't fit in.

Moore says he was always fascinated with aviation, but his interest peaked during World War II while serving as a physician in the Philippines. Talking with Navy pilots fueled his interest in flight, as did some of the flights he took with those Naval aviators.

Eventually, 10 years after setting up his practice, he decided it was time to learn to fly. He called on another longtime Harnett County resident and aviator for help.

"I talked to Gene Stewart, who taught flying during the war," Moore recalled. "I told him, `I think I want you to teach me to fly.' He had stopped teaching for a while, but he got back into it and continued to teach for quite a while."

Stewart taught Moore to fly in a Super Cub. He soloed that plane at the

Harnett County Airport near Erwin, N.C. He bought a Tri-Pacer after getting his private pilot's license in 1960.

During the same year he earned his license and bought his first plane, he decided to meet the FAA requirements to give pilot physicals. Eventually, he became the only doctor between the large cities of Fayetteville and Raleigh certified by the FAA to issue all classes of medicals. He says it's only natural for a doctor who flies to want to provide the service of flight physicals.

The Tri-Pacer was sold during the mid 1960s and Moore upgraded to a Mooney. It's obviously a plane he was very fond of. A picture of that Mooney still hangs inside the office where he performs his examinations on pilots. He actively flew until a few years ago.

One of the pleasures of giving flight physicals is in getting to know the pilots and some of the "characters" in aviation, Moore says. But being a doctor for pilots isn't always rosy. Moore

has always found it difficult to inform a pilot that he or she no longer meets the FAA medical requirements.

"I'm always reluctant to have to tell them," he says. "But, I think they understand you just can't get around some of the very specific requirements."

Moore has seen a great deal of change in both planes and pilots the past 41 years. When it comes to aircraft, he notes the biggest change is in navigation. "By far, the biggest change has been in the electronics. When I started, everything was based on homing in on a station, using ADF. Today, everything is so advanced and easier," he said, noting how he finds today's systems, such as GPS, fascinating.

When it comes to pilots, the change Moore notes should come as good news for those of us who hope to fly for a long time. "Some of the health problems are about the same, but for the most part pilots are healthier today," he said. Q

The next issue of the Bulletin will feature

Dr. James E. Moore, a Stamford, Conn.,

This article is reprinted with the permission of: General Aviation News, P.O. Box 39099, Lakewood, WA 98439. To contact the editorial staff, their E-mail address is: comments@

aviation medical examiner who will observe his 56th year in aviation medicine on March 1, 2003. --Ed.

T h e F e d e r a l A i r S u r g e o n ' s M e d i c a l B u l l e t i n ? Winter 2002 5

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